Do You Have the Right Tools for Your Practice?

by Jennifer Heller, MD

Long regarded as the beleaguered stepchild of vascular surgeons, venous disease is finally coming into its own. And that’s really an understatement. It seems that there isn’t a day that passes by without a gorgeous leg splayed across a glossy magazine cover, or radio ads cheerily introducing vein centers. Even Dr. Oz has participated in this vein frenzy. About a year ago, he devoted an episode to discussion of spider vein treatment.

Certainly one can regard this as spectacular news. The public is becoming educated on a disease process that can negatively impact their daily activities. Myths about the benign nature of all varicose veins are being debunked. Patients can receive treatment and experience improvement very rapidly.

But, as a vascular surgeon, I tend to be a bit more skeptical, and as an academic vascular surgeon who focuses on venous disease, I have a very unique perspective. I am participating in this vein revolution from both within and outside of the ivory tower of academia. Over the past eight years, I have developed and served as director of the Hopkins Vein Centers. The clinical and research growth has been gratifying and exhilarating. As a result, we have developed multiple sites to accommodate our volume. The staff within our centers includes advanced level practitioners and vascular surgeons. My colleagues perform the entire spectrum of vascular disease, whereas I devote my practice to the venous circulation. But our physician heterogeneity stops there.

I also participate as a consultant for Covidien’s Vein Course to educate physicians. At first glance, this might not seem terribly interesting. Education is a cornerstone of what we do in academia: teaching medical students, residents, and fellows, and participating in division conferences and walk rounds. Teaching is teaching, isn’t it?

But the unique aspect of my endeavor is that the physicians who take these vein courses are rarely vascular surgeons. This is a trend that has actually accelerated since I started teaching the programs. Now, most courses will have, at most, a few vascular surgeons as participants. At least within these courses, the physician specialty demographic has shifted, predominantly to interventional cardiologists and interventional radiologists. My theory on this is that venous disease has become more interesting to most every lay and medical group—with the exception of vascular surgeons. Medical students and residents are not choosing vascular surgery for chronic venous disease. Early to midcareer vascular surgeons are concentrating on advanced arterial endovascular skills and infrainguinal disease. Arterial disease is the backbone of most vascular surgeons’ practices, as well it should be.

There are certainly prominent vascular surgeons who are performing outstanding investigative work on venous insufficiency on both the bench and in the clinic. The American Venous Forum is a vibrant, rich, organization. However, for the time being, in my opinion, the vascular surgery community is not giving venous disease the attention it deserves. If more vascular surgeons were actively incorporating venous disease into their practice, I expect that there would be less room for other physician specialties to participate.

The treatment of superficial venous insufficiency has been revolutionized with the advent of endovenous therapy. The technique is easy, quick, requires minimal setup, and can be performed without anesthesia. Advanced surgical skill is not needed. Any physician who has catheter skills can easily learn the procedure.

Here’s the disconnect: Although the technology has changed, the disease process hasn’t. And as treatment for venous insufficiency has moved out of the operating room and into offices, it has become an attractive method for physicians to expand their practices and revenue. Venous insufficiency has started to become more like an appealing business venture, easy and low risk, rather than a disease.

It is for these reasons that I teach these courses. Medicine is medicine. When one permits ease and low risk to supersede the importance of safety and ethical medicine, one needs to hang up his hat. By all means improve your lifestyle, prevent burnout, and judge your personal needs so that you don’t overwhelm your professional obligations. But don’t sacrifice your integrity. Make sure that you embark on learning the entirety of venous disease before slamming a catheter into someone’s leg.

The practice of medicine isn’t about a particular technique. We surgeons joke that we could teach monkeys how to do some of our cases. The difficult parts of surgery are not the acts of operating; it’s everything else. It’s when not to take the patient to the operating room and understanding the natural history of the disease. It’s how and when to choose a particular operation over another. It’s the process of explaining to your patients the risks and benefits of the treatment plan and how together to make a logical decision.

Would I prefer to teach these courses to a room full of vascular surgeons? Sure, absolutely. I am loyal to my training and to my mentors. But if the choice is to provide comprehensive knowledge to physicians who are going to be performing these procedures regardless of my participation, I would much prefer to educate and integrate. Because that’s what medicine is all about.